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Environmental Health Department <br />10. <br />OR <br />12. <br />13. NarTmcfmspomfctepmomtolMpm^inboothdurlnoalhcHncfopwa^ <br />14. Completed by: <br />SlgiMture <br />Health Pennit <br />PattrlMTaMk <br />C2i <br />*K*mTa* <br />JI WMiiw—r <br />Ice Cooler <br />pieMtfii TSMPe«HT.*M' <br />WMaMUrCxMw <br />maewwir I <br />taNattaM* <br />Ma*taMn*r <br />i*»ii <br />£6 Water supply dtaponsor wfth warm water at a mWmum oTttXFF {Le. 540oalon container with apigaQ. <br />One separate tub (bucket or basin) for the coaection of rineo/waatewater. <br />M# 0* HMMAMr <br />GaAag* <br />Can <br />Boothmuatbeon <br />Concrate. AsphaM. <br />Plywood, or a Tatp. <br />SAN JOAQUIN <br />COUNTY <br />[aangaMgi |. <br />WwanaSMa . <br />r r»rr» »w« * rriutrriw— <br />*M«MaMtf«NonM <br />MmawCkM^ <br />ow» <br />lam providing the following Mams within my booth for the santery eteening of food preparation utensl <br /> Three compartment sink. <br />’ .thB fc*owin9 «** temperrtwe control for the cold holdfog of potentHV hazardous foods below <br />4CT (if food to used the folowfog day, mafotato below 41T temperature): <br />Qlcecbesta Refrigoralor <br /> Refrigerated truck JO Ice bath and tube <br />O Other (specify) <br />fi|T>Mce ** •0-W ’•'■for. on* for rinsing and one for a btoech <br />Q Detergent, bleach, and wiping clolhs (cleanfog towels). <br />Tub to store wtofog cloths In btoech solution. <br />I am providing the Moving for adequate hand washing focMes. but separate from utensfl wash within my <br />booth: <br />All food vendor booths are subject to inspection. Please make a copy ofthis sppHcabon in <br />preparation for this event A copy of this cheddM must be In the booth at aB hours of <br />preparation and operation. Ratunt orfofrwl to fosdysl rreordlnatoc three write rafor to <br />Title Date <br />1868 E. Hazelton Avenue | Stockton, CaRfomla 862061 T 209 468*34201 F 209 464*0138 | www.sjwhdcOTn—rr—-